Healthy Skepticism International News

Newsletter Sep/Oct 1997

Vol 15 Issue 9/10
Reports: An overview of promotion Part 2
Second of 3 parts expanding on a report titled Healthy Profits written by Melissa Sweet for the Sydney Morning Herald.

Healthy Profits: An overview of promotion in Australia Part 2

Introduction

This edition presents part two of an article written by Melissa Sweet and published in the Sydney Morning Herald on 25 October 1997. The third and final part will be published in the next edition.

Melissa Sweet’s article as published appears below in our usual Times New Roman font. We have added some comments, which appear in (brackets in Ariel font).

HEALTHY PROFITS (Part 2)

By Melissa Sweet

Dr Linda Mann laughs, quite delightedly, when saying that she probably does not represent the “majority” of GPs. She certainly does not seem as conservative as many of her colleagues. Mann also differs in other ways. The practice where she works at Leichhardt rarely sees more than two drug company reps a week.

(Perhaps Melissa Sweet had intended to interview a representative, average GP. However, GPs are a very heterogeneous group.

We are not aware of publicly available reliable data on how often doctors see drug company representatives in Australia. Many French doctors see around 8 “reps.” per week.1 This may be part of the explanation for the very high prescribing rates in that country.

It has been estimated that only 15% of Australian doctors completely refuse to see “reps.” but companies are now finding it increasingly difficult to get access to doctors.2 Access to doctors is a very important and emotional issue for drug companies. This is because “reps.” are the most effective component of companies’ influence on prescribing.

In appears that loss of access is motivating some companies to consider improving their “quality of service”, perhaps even by being more honest. However, companies with a deeply entrenched corporate culture of believing their own propaganda, must face the difficult task of being honest with themselves before they can be honest with their “customers”.3,4)

Mann believes [drug reps] are an important source of education, but has no qualms about giving them a tough time if they try to make misleading claims. “I’ve sent reps out of here so unhappy that they’ve taken away the lunch they brought for the doctors,” she says.

Many doctors are reluctant to acknowledge that drug marketing, particularly the regular visits from company reps, affects the way they practise medicine. Mann says: “I would like to think that they don’t influence my prescribing, but I happen to know that they do because I have audited my own prescribing.”

(Self-audit of prescribing is an unusual but very worthwhile continuing medical education / quality assurance activity. If Dr Mann was surprised to learn that she is so heavily influenced by “drug reps.” then she is no exception.

Dr Mann’s views are consistent with the literature which suggests that most doctors have little awareness of being influenced and tend to believe that they are able to detect misleading claims. Unfortunately they are influenced and they are unable to detect many misleading claims.5 As MaLAM secretary Joel Lexchin concluded in 1989 “seeing detailers is detrimental to the practice of good medicine, and the best interests of doctors and their patients would be served if [doctors] had nothing further to do with detailers.“6 Some drug companies have improved since then, but they still have a long way to go before MaLAM could support any other recommendation.)

Many studies have documented the influence of industry marketing on doctors (see page 4). “There’s no doubt that the biggest influence on prescribers is pharmaceutical industry promotion,” says Richard Day, professor of clinical pharmacology at the University of NSW and a long-term advocate of the need to improve use of medicines.

Peter Mansfield is an Adelaide GP who has become notorious within the pharmaceutical industry as the tiny, annoying thorn in its mega-side. Fourteen years ago, he established Medical Lobby for Appropriate Marketing (MaLAM) after being outraged that a multinational company was promoting anabolic steroids for impoverished, starving children in Bangladesh when they needed better nutrition.

Since then, agitation by his group, with a budget this year of just $18,000 has led to medicines being withdrawn and much advertising being rewritten.

Mansfield is careful about what he says for this interview, having recently been threatened with legal action after complaining about a company’s promotions. (We plan to report on this threat in a later edition.) But he happily recites the selling techniques of drug reps (see page 4), including that they tend to be attractive young women who are more likely to appeal to male and female doctors. He adds: “We are more likely to be influenced by people we like.”

“Wendy”, a former drug company rep and product manager (and an attractive extrovert) disagrees with some of Mansfield’s assessments. “The guy with the beer gut in my company was the top salesman,” she says. But she adds that many doctors were happy to see her. “You’re not sick”, she says. “The more you got to know them, sometimes they’d see you while they had patients waiting; you’d be making the visit fun, you’d be smiling, you’d be listening to what their issues are.”

(Sex appeal is only one of many ways to be likeable. The overweight top salesman may have made up for being less attractive by having years of practice at being friendly and/or using the other sales skills. Alternatively, he may have out performed younger “reps.” only because he worked long enough to built up friendly relationships with doctors during multiple visits over many years. See page 4.)

The industry also uses more subtle techniques to build relationships with doctors. Karen, a nurse, spent six months a few years back working for Merck Sharp & Dohme, in a big program that offered GP’s patients free screening for heart disease risk factors. Those with elevated cholesterol or a combination of other risk factors were referred back to their GP. “They promoted it as a genuine, hands-off exercise, but as things developed, I felt it was more of a public relations exercise and a way of getting patients onto their (Cholesterol-lowering) medication” she says. The company emphasises the program is accredited for continuing medical education and that doctors who participate are not required to prescribe MSD drugs.

(Emphasising that there are “no strings attached” may increase the subconscious sense of reciprocal obligation.)

The days of extravagant gifts and hospitality for doctors are mostly gone, but the industry has turned to more subtle techniques: it targets opinion leaders, funds continuing medical education programs approved by the various medical colleges, establishes educational awards for health professionals or buys medical equipment.

(These more subtle techniques are more difficult to control and may be just as effective as the old methods.)

The Australian Medical Association and the Royal Australian College of Physicians have adopted codes of ethics that discourage doctors from accepting gifts and the Royal Australian College of GPs is developing guidelines. Fiona Woodard, the secretary of the APMA code of conduct subcommittee, says the code has been significantly tightened; gifts should be given only if they are brand-name reminders or part of medical education and any hospitality to doctors must now be secondary to an educational component.

(During October to December 1997,ICI offered a $1,000 travel voucher for a business or personal trip, ten dinners for two @ $120 and 10 bottles of champagne to GPs who provide information to assist the company to promote its drugs with $130 perfume packs for their receptionists. We have notified the APMA.)

But Dr Tony Jorm, an epidemiologist at the Australian National University, argues that too many doctors are still accepting gifts which may compromise their ability to put patient’s interests first. When Jorm recently raised these concerns in The Medical Journal of Australia,7 there was an angry response from a Queensland GP, David Graham: “Like most rural GPs I am constantly overbooked with patients, but I make time for pharmaceutical representatives whenever possible to refresh my memory about an older drug or learn about a new one. The bald fact is that each 15 minutes spend in this way costs me about $30. If I get a few pens or balloons for my kids it seems little enough in exchange for me.“8

(Dr Graham also wrote: “Another factor which is disregarded in the equation is the incredibly short attention span of my colleagues and me! In less time than it takes to put the gift in my bag or drink the first Chardonnay at the meeting, I have forgotten the drug to which it relates.” This argument suggests that gifts are not effective but the reality is otherwise. In fact it is the lack of conscious awareness that enables the message to bypass critical appraisal and thus influence behaviour subconsciously.)

Associate Professor John Turnidge, director of microbiology at the Women’s and Children’s Hospital in Adelaide, says companies still occasionally invite him to football or tennis matches. “I don’t think that’s acceptable any more,” he says. “I (went) once and then felt extraordinarily guilty.” This year he knocked back an offer of free air tickets to Melbourne during the Grand Prix.

A senior specialist at one of Sydney’s big teaching hospitals recalls that he was one of many doctors to see The Power of One, courtesy of Roche, whose marketing for a new antibiotic emphasised that it needed to be given only once a day. The doctor declined to be named for this article because he wants to maintain good relations with the industry; “I don’t want to be too critical (of their tactics) because I’ve been their guest at dinners and conferences on several occasions.”

The industry also has an enormous influence on medical publications. A senior doctor has described being approached by a PR company to write an editorial for a medical journal: the company would write the article, which he could modify, thus earning $US 2,500. The offer reflected the growing influence of the pharmaceutical industry on medical care, he wrote in The New England Journal of Medicine.9 An editorial in the same journal recently dismissed the findings of an accompanying study raising safety concerns about an obesity drug.10 It was written by two “experts” who were later found to have a long history as paid consultants for related companies.11

(The obesity drug was dexphenfluramine, which has since been withdrawn worldwide because it damages heart valves.)

Closer to home, a former editor of The Medical Journal of Australia admitted, after receiving letters of complaint from doctors,12,13 that the journal had been forced by financial constraints to allow advertisements to be placed near editorial on related topics. “We all hope that an economic upturn will allow us to return to the purity of former days,” Dr Laurel Thomas wrote.14

SWEETENING THE PILL

How Drug Companies Influence Doctors.

American researchers have found that physicians are more likely to ask their hospitals to stock new drugs if they have accepted money from companies to attend or speak at educational symposia or to perform research, or have met sales reps from those companies.15 Another study found that marketing influenced doctors’ prescribing to the extent that they tended to prescribe analgesics according to advertising rather than published scientific literature.16 One study, with the tongue-in-cheek title A Food-Borne Outbreak of Expensive Antibiotic Use in a Community Teaching Hospital, documented the increased use of a costly antibiotic in a hospital after its doctors attended an extravagant dinner party hosted by the manufacturer.17

1. Gifts, even pens, create a sense of mutual obligation that subconsciously makes the doctor want to please the rep.
2. Appeals to authority, such as mentioning that a specialist the GP respects is using the drug.
3. Peer pressure – mentioning that the other GPs in the area are using this drug.
4. “Commitment consistency”, which involves inviting the doctor to agree to a motherhood statement, such as “you’d agree that you need to know about treating hypertension” as a tactic for getting the doctor to agree to hear about the new drug.
5. Being friendly.

(This classification comes from the work of Cialdini, a social psychologist who studied a personal selling of a wide range of products eg door-to-door encyclopedia sales.18 He identified 6 methods of influence, which take advantage of human decision making short cuts. The sixth method not mentioned above is use of scarcity - the perception that something is more valuable because it is rare or available for a limited time only.

All of the five methods mentioned above have been detected in use many times in a study of audio recordings of GP - drug rep encounters in Melbourne.19 Melissa Sweet’s interview with the author of this very important study will be reported in the next MaLAM edition.)

Canadian researchers recently identified 20 published articles and several unpublished ones claiming to show benefits for a new antipsychotic drug, risperidone, which was heralded as an important milestone in the treatment of schizophrenia. After lengthy investigation, however, they concluded that only two large and seven small trials had been done – but the results had been reported several times, often deliberately disguising that they were results previously published elsewhere under the name of other authors. The researchers did not identify who had been responsible for this subterfuge, but concluded that such practices “have begun to subvert the role of medical publications from the unbiased reporting of data to the dissemination of information that carries with it a personal or corporate agenda”.20

The Journal of the American Medical Association records that a US Senate inquiry several years ago was told of companies: sending doctors and their spouses on all-expenses-paid trips to exotic destinations, including Acapulco and Monte Carlo; offering physicians $US 1,200 to prescribe an antibiotic to 20 patients in a “clinical study”; awarding frequent flier points for every prescription written; offering a physician $US100 to read company literature that encouraged the prescribing of a highly toxic drug for a use not approved by the Food and Drug Administration.21

More of Melissa Sweet’s article will be published in the next MaLAM edition.)

I find the Healthy Skepticism Updates extremely useful and I open many of the links with interest.
- Tom Perry MD, Vancouver

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